| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,476 |
2,465 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
1,295 |
1,293 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,203 |
551 |
$81K |
| D1310 |
|
1,320 |
1,312 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
864 |
859 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,451 |
2,440 |
$52K |
| D1351 |
Sealant - per tooth |
1,121 |
377 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,126 |
1,459 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
300 |
171 |
$16K |
| D0603 |
|
972 |
967 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
140 |
138 |
$10K |
| D0272 |
Bitewings - two radiographic images |
792 |
789 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
151 |
100 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
663 |
654 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
121 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
41 |
$4K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$2K |
| D9110 |
|
17 |
17 |
$1K |
| D0601 |
|
12 |
12 |
$180.00 |